A previously healthy 24-year-old man is brought to the emergency department after a bicycle crash. The patient was mountain biking downhill when he struck a prominent tree root and was thrown from his bike. He tried to brace his fall with his hands, but his chest struck a large rock as he landed. He did not hit his head or lose consciousness. The patient has moderate central chest pain and severe right wrist pain. Blood pressure is 142/86 mm Hg, pulse is 110/min, and respirations are 20/min. Oxygen saturation is 98% on room air. Physical examination is significant for sternal bruising with point tenderness, abrasions on both palms, and a deformed right wrist with an overlying laceration. Breath sounds, heart sounds, and abdominal examination are normal. Focused assessment with sonography for trauma is negative for free intraabdominal or pericardial fluid. Noncontrast CT scan of the chest reveals a hairline sternal fracture. Radiographs of the right wrist reveal a severely displaced, open fracture of the right distal radius. The patient is hospitalized for operative irrigation, debridement, and fixation of the wrist fracture. Throughout the day, the patient is noted to be persistently tachycardic even though he is afebrile and normotensive, with normal respirations and oxygen saturation. Pain control is adequate. ECG shows sinus tachycardia with frequent premature ventricular contractions. Which of the following is the best next step in management of this patient?

Question

A previously healthy 24-year-old man is brought to the emergency department after a bicycle crash.  The patient was mountain biking downhill when he struck a prominent tree root and was thrown from his bike.  He tried to brace his fall with his hands, but his chest struck a large rock as he landed.  He did not hit his head or lose consciousness.  The patient has moderate central chest pain and severe right wrist pain.  Blood pressure is 142/86 mm Hg, pulse is 110/min, and respirations are 20/min.  Oxygen saturation is 98% on room air.  Physical examination is significant for sternal bruising with point tenderness, abrasions on both palms, and a deformed right wrist with an overlying laceration.  Breath sounds, heart sounds, and abdominal examination are normal.  Focused assessment with sonography for trauma is negative for free intraabdominal or pericardial fluid.  Noncontrast CT scan of the chest reveals a hairline sternal fracture.  Radiographs of the right wrist reveal a severely displaced, open fracture of the right distal radius.  The patient is hospitalized for operative irrigation, debridement, and fixation of the wrist fracture.  Throughout the day, the patient is noted to be persistently tachycardic even though he is afebrile and normotensive, with normal respirations and oxygen saturation.  Pain control is adequate.  ECG shows sinus tachycardia with frequent premature ventricular contractions.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8a5_bce8_bc81_611170a6733f_MD0003_00 This patient who sustained blunt chest trauma (eg, sternal fracture from the chest striking a rock) has persistent tachycardia and new arrhythmia (frequent premature ventricular contractions), both of which are concerning for blunt cardiac injury (BCI). BCI can induce myocardial edema, hemorrhage, and necrosis capable of causing a spectrum of structural, ischemic, and electrical complications. The electrical disturbances are frequently subtle and asymptomatic, as in this patient, but they require further monitoring and evaluation because they may be a sign of more severe cardiac sequelae. Patients with findings concerning for BCI require 24-48 hours of continuous cardiac monitoring because most life-threatening arrythmias occur during that time. In patients with significant findings (eg, arrythmias, hypotension, heart failure), echocardiography is performed to evaluate for myocardial dysfunction and/or structural (eg, valvular) injuries. Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) but is also more invasive; therefore, in this nonintubated, hemodynamically stable patient, transthoracic echocardiography is the best next step. (Choice A) Coronary angiography is appropriate for suspected acute coronary syndrome, which can be caused by traumatic coronary dissection or thrombosis. However, acute coronary syndrome is less likely in patients without ischemic changes (eg, ST-segment changes) on ECG. (Choice B) CT pulmonary angiography can diagnose pulmonary embolism, a possible complication of trauma due to the inflammatory prothrombotic state. In contrast to this patient, those with pulmonary embolism often have tachypnea, dyspnea, and/or hypoxemia. (Choice C) Esophagography with water-soluble contrast is the best initial study for suspected esophageal rupture. Although spillage of gastrointestinal contents from esophageal rupture can cause a systemic inflammatory response that includes tachycardia, the systemic inflammatory response typically causes fever, which is not seen in this patient. (Choice D) Open fractures have increased infection risk compared with closed fractures, and the standard of care involves immediate (<3 hr postinjury) intravenous prophylactic antibiotics and urgent (<6 hr) surgical irrigation and debridement. Although open fractures can cause bacteremia, local infection (eg, soft tissue infection, osteomyelitis) is much more common, and peripheral blood cultures are not typically drawn, especially in the absence of fever. (Choice E) Thyroid function tests can diagnose thyroid storm, which may be incited by trauma. Clinical manifestations of thyroid storm include tachycardia; however, hyperpyrexia and hypertension are also typically present. Educational objective: Persistent tachycardia and new arrhythmia (eg, premature ventricular contractions) after blunt chest trauma are concerning for blunt cardiac injury. Patients with these findings are admitted for continuous cardiac monitoring and echocardiography. References: Blunt cardiac trauma: a review of the current knowledge and management. (http://www.ncbi.nlm.nih.gov/pubmed/25069684) Blunt cardiac trauma review. (http://www.ncbi.nlm.nih.gov/pubmed/29173678)

A Previously Healthy 24-Year-Old Man Is Brought to the Emergency